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View After Cancer Surgery is Good for F.B.I. Director

August 15, 2001

Wednesday, August 15, 2001
By Lawrence K. Altman with
David Johnston

 

WASHINGTON, Aug. 14 Nearly two weeks ago, on the day the Senate unanimously confirmed Robert S. Mueller III as the new director of the Federal Bureau of Investigation, he was in an operating room in San Francisco where surgeons removed his cancerous prostate gland.

His urologist and surgeon, Dr. Peter R. Carroll, discussed Mr. Mueller's cancer, his operation and his prognosis in a detailed interview with a reporter for The New York Times, who is also a physician. Dr. Carroll said Mr. Mueller has a "very high likelihood of cancer cure," is in excellent physical and mental health, and is fit to serve the 10-year term as F.B.I. director.

The timing of the 2 1/2-hour operation and the confirmation vote on Aug. 2 was a coincidence. Mr. Mueller, who learned that he had prostate cancer last fall and was told he could wait for treatment, had scheduled the surgery this summer, said Dr. Carroll, who is the chief of urology at the University of California at San Francisco.

Mr. Mueller, 56, had postponed his swearing-in pending the outcome of the operation and the pathology report. He did not want to assume his new position until he had recuperated and was ready to perform his duties fully, his associates said.

The pathology tests showed that the cancer was confined to a small area of the prostate, and Mr. Mueller (pronounced MULL-er) needs no additional therapy, Dr. Carroll said.

This year, 198,100 cases of prostate cancer will be detected among Americans and 31,500 will die from it, the American Cancer Society says. Statistically, an American man has a 16 percent chance of developing prostate cancer during his lifetime and a 3.4 percent chance of dying from it.

Four days after his operation, Mr. Mueller was at work, part time, preparing to leave his job as the United States attorney in San Francisco.

Most men do not return to vigorous work for about four weeks after the surgery, although many return to more sedentary work sooner. "But if you have a highly motivated man, it is hard to keep him from going back to work," Dr. Carroll said.

Mr. Mueller will determine for himself when he can start work, Dr. Carroll added.

Except for skin cancer, prostate cancer is the most commonly diagnosed type in men and their second leading cause of cancer death, behind lung cancer. Prostate cancer usually takes years to grow and spread, if it ever does.

Mr. Mueller disclosed his cancer to administration officials before he was selected for the F.B.I. post. The Senate Judiciary Committee received a letter dated June 20 from Dr. Carroll affirming the diagnosis and giving a favorable prognosis. But in the letter Dr. Carroll did not provide the details that he did in recent interviews. Mr. Mueller declined to be interviewed about his health, but Dr. Carroll spoke with his permission.

Mr. Mueller's cancer was detected the way most such cancers are found today by a blood test in a checkup. The blood test measures a protein known as P.S.A., for prostate specific antigen. The prostate produces it as part of the ejaculate to help sperm swim, but a small amount normally escapes into the blood.

Mr. Mueller's prostate felt normal to all physicians who have examined him in Washington and California since last September, Dr. Carroll said. But at that time his P.S.A. was slightly elevated at 5.5 nanograms per milliliter. The number is usually less than 4, although it can vary according to age, the laboratory performing the test, and other conditions like prostate inflammation.

But the test is not perfect. Its number can be elevated in the absence of cancer, and it can be normal when cancer is present. Also, the test cannot distinguish between cancers likely to be harmless and those that will kill.

To exclude a laboratory error, Mr. Mueller's level was measured a second time. Again it was elevated. So the doctors performed another test. Normally some antigen is bound to other proteins in the blood and some flows freely. The more specific test measures the proportion of each.

The proportion that is bound tends to rise when cancer is present and the free-flowing portion tends to be higher when the patient has a noncancerous prostate enlargement. Thus, the lower the percentage of P.S.A. that is free, the stronger the likelihood of cancer. In Mr. Mueller's case, the free fraction was 8 percent, consistent with cancer.

In late fall, a urologist performed two biopsies of Mr. Mueller's prostate. The first showed that he had a small amount of prostate cancer that was confined to one area. The second showed no evidence of cancer.

A magnetic resonance imaging test showed no evidence that the cancer had spread.

As the doctors continued to monitor the antigen level, it crept up, ranging from 5.5 to 7.7, and the free- fraction proportion stayed low.

Some prostate cancers grow and spread rapidly; many others grow slowly and never cause a problem. But doctors have no way to know which patient has which form, and no single test provides an accurate diagnosis or prognosis. However, doctors put much emphasis on what they call the Gleason score to gauge the tumor's aggressiveness.

The score, on a 2-to-10 scale, is based on a pathologist's view through a microscope of how much the cancer differs from the normal architectural pattern of the prostate. Usually, the lower the score, the better the chance of a cure.

Mr. Mueller's first score, based on the biopsy, was midrange at 6.

Depending on the score and other findings, many men take months to decide on a therapy. "We strongly encourage men not to rush, not to make treatment decisions quickly," Dr. Carroll said.

In April, when Mr. Mueller first went to Dr. Carroll, the urologist repeated some tests and asked pathologists for a second opinion on the tissue removed in the biopsies. The San Francisco and Washington pathologists agreed on the findings.

"We discussed many different treatment options including watchful waiting," Dr. Carroll said, because "we do not think these are the kind of cancers that require immediate attention and that men would do much better by understanding their options and exploring them further."

Mr. Mueller consulted a radiation oncologist to discuss two types of therapy external beam and implantation of radioactive seeds before deciding on surgery.

Pathology tests on the prostate removed in the operation showed "a moderately differentiated tumor confined to a single" piece of tissue and no spread to lymph nodes or other areas, Dr. Carroll said. "It looks as though the cancer is completely excised," he added.

The Gleason score of the tissue removed in the operation was 7. That was higher than the score from the biopsy, thus slightly lowering the odds for a complete cure. Still, Dr. Carroll said Mr. Mueller had better than an 80 percent chance of not having any recurrence or significant disability from cancer recurrence.

"You can never say 100 percent," Dr. Carroll said.

Two urologists not connected with Mr. Mueller's case concurred with Dr. Carroll's assessment.

Dr. David G. McLeod, chief of urology at Walter Reed Army Medical Center who performed similar prostate surgery on former Senator Bob Dole, said he agreed "100 percent with Dr. Carroll."

"I would tell Mr. Mueller that he had a bump in the road and to go on with his life," Dr. McLeod said.

Dr. Michael J. Droller, chief of urology at Mount Sinai Hospital in Manhattan where Mayor Rudolph W. Giuliani was treated with radiation for prostate cancer, said that although Mr. Mueller's final Gleason score was higher than in the original biopsy, the pathological finding that the cancer was confined to the prostate signaled a favorable prognosis.

Most patients recover faster after prostate surgery because of a number of improvements in urology, Dr. Carroll said, including smaller incisions (about five inches, instead of 10), improved surgical techniques that greatly reduce the need for transfusions (Mr. Mueller had none), and early and judicious use of nonsteroidal pain medication.

Such changes allowed Mr. Mueller, like many others, to leave the hospital two days after the operation.

 

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